Can atorvastatin (lipitor) be discontinued in an elderly patient with peripheral vascular disease (PVD)?

Should Atorvastatin Be Discontinued in an Elderly Patient with PVD?

No, atorvastatin should NOT be discontinued in an elderly patient with peripheral vascular disease (PVD). PVD is established atherosclerotic cardiovascular disease (ASCVD), making this secondary prevention, where statin therapy provides substantial mortality and morbidity benefits regardless of age.

Why Continuation is Critical in PVD

Peripheral vascular disease represents established ASCVD, and secondary prevention guidelines strongly support continued statin therapy in older adults with documented vascular disease. 1 The evidence is compelling:

• Older patients with PAD specifically benefit from cholesterol-lowering therapy, with studies showing 24% and 42% increases in treadmill walking time before onset of claudication at 6 and 12 months after statin initiation, respectively 1
• Discontinuing statins in patients with established ASCVD increases short-term mortality and major adverse cardiac events, with statin-adherent patients being half as likely to experience subsequent myocardial infarction compared to non-adherent patients 2
• High-intensity statin therapy in PAD patients was associated with improved survival (hazard ratio for mortality: 0.52) and decreased major adverse cardiovascular events (hazard ratio: 0.58) compared with low-moderate intensity therapy 3

Evidence Supporting Continuation Through Age 85

The American Heart Association scientific statement explicitly states that "overall evidence supporting lipid lowering medication for secondary CHD prevention is credible through about age 85" and that "secondary prevention guidelines advise lipid lowering therapy 'regardless of age' in the majority of older patients with ASCVD unless issues of frailty, comorbidity, and polypharmacy confound management." 1

Key supporting data:

• In patients ≥65 years with CHD, statins reduced all-cause mortality by 22%, CHD mortality by 30%, non-fatal MI by 26%, and stroke by 25% 2
• Meta-analysis of 19,569 older CHD patients (65-82 years) showed NNT=28 to save one life 1
• The absolute risk reduction is actually HIGHER in older patients due to their elevated baseline risk, making the number needed to treat lower than in younger patients 1, 4

Appropriate Dosing Strategy for Elderly Patients

Rather than discontinuation, moderate-intensity statin therapy is recommended for patients >75 years with established cardiovascular disease 4, 2:

• Atorvastatin 10-20 mg daily is the appropriate moderate-intensity dose for elderly patients with PVD 4, 2
• High-intensity dosing (40-80 mg) should be avoided in very elderly patients due to increased adverse event risk without additional benefit 4
• Target 30-40% LDL-C reduction from baseline rather than absolute targets in very elderly patients 4

When Discontinuation May Be Reasonable

Discontinuation should only be considered in specific circumstances 1, 4:

• Functional decline (physical or cognitive) where quality of life takes priority 4
• Severe frailty with limited life expectancy (<3 years) 4, 5
• Multimorbidity with polypharmacy causing intolerable side effects 1
• Age >85 years WITH concurrent severe frailty and comorbidities 1

Critical Pitfalls to Avoid

The most common error is premature discontinuation based on age alone rather than functional status. 2 Additional pitfalls include:

• Misperception of risks and benefits is the most common factor leading to non-adherence, with physician or patient preference accounting for 55% of discontinuation in clinical trials 2
• Even brief discontinuation of statins might be harmful in patients with established vascular disease 6
• Statins are notoriously under-prescribed and under-dosed in elderly patients despite their higher risk of recurrent events 1

Monitoring Recommendations

If continuing therapy (which is recommended):

• Assess adherence and LDL-C levels 4-12 weeks after any dose adjustment 4
• Monitor for muscle symptoms at baseline, 6-12 weeks after starting therapy, and at each follow-up visit 5
• Evaluate for drug interactions, particularly with polypharmacy common in elderly patients 4, 5
• Consider dose reduction if two consecutive LDL-C values are <40 mg/dL 5